Foot and Ankle Surgery

When rheumatoid arthritis (RA) affects the joints of the foot, it can make a range of common activities, including basic walking, difficult or impossible. This can lead to significant disability.

The foot and ankle are mechanically and structurally complex, containing over 20 bones and 30 joints, along with the many muscles, tendons, and ligaments that connect them and allow for movement and function. The foot is divided into 3 regions, including the forefoot, mid-foot, and rear- or hind-foot). There are several different surgical procedures (described below) that may be performed on the foot and ankle of a person with RA.

How RA affects the feet

The feet, similar to the hands, are often affected in the early stages of RA. Approximately 13% of RA patients will have foot symptoms as the first signs of RA. In addition, it is estimated that more than 90% of people with RA will have foot involvement at some point in the course of condition. Typically, RA symptoms will affect both feet. However, the deformities that appear in each foot may differ due to differences in how weight is distributed between the feet and differences in inflammation.1,2

In RA, the top of the foot may become red and swollen. Joints at the base of the toes (between the phalanx and metatarsal bones) may become tender, making it painful to walk and causing the patient to shift weight to the heel and bend the toes upward while standing or walking. Joint erosion resulting from chronic inflammation may lead to migration or drift of toes towards the side of foot. Changes to the forefoot that are common in patients with RA include bunions, claw toes, hammer toes, “cock-up” deformity of the fifth toe (the small toe), and pain affecting the ball of the foot. In some patients, the heel may also become painful.2,3

Surgery for the feet

If joint symptoms do not respond to medication or other management approaches, surgical interventions may be used. Surgical options include arthrodesis, which involves removal of the joint and fusion of two bones into one. Other surgical options (mainly available for the front of the foot) include procedures that correct joint damage (e.g. hammer toes) and spare joints.3

Hindfoot

The hindfoot is the region of the foot that is close to and including the heel. This part of the foot creates a side-to-side motion.2 Surgery for RA in the hindfoot usually involves fusion, in which the damaged cartilage is removed and the bones are held together using screws, plates, or rods. A triple arthrodesis is a procedure that involves fusing all three of the joints in the hindfoot. This reduces the range of motion but improves function and pain.2,3

Midfoot

When RA affects the midfoot (middle portion of the foot), the ligaments can be damaged, causing the arch of the foot to fall, or the cartilage may be damaged, causing pain. As RA progresses, the midfoot may develop a bump (bony prominence), which can make wearing shoes difficult. Surgery to the midfoot most often involves fusion to restore the normal arch of the foot and decrease changes in the shape of the foot that have resulted from damage to joints. The goal is to reduce pain and allow the patient to wear normal shoes. Arthroplasty or joint replacement is available for joints in the outside of the mid-foot and may be used to preserve some degree of mid-foot motion.2

Forefoot

The forefoot includes the toes and ball of the foot. Choice of surgical treatment for the forefoot to correct deformities depends on the nature and extent of joint damage. If damage is less severe, joint sparing procedures may be used to preserve motion. For the big toe, fusion of joints (arthrodesis) may be used if there is significant cartilage damage. In cases of significant deformity, surgery involving fusion of selected joints, removal of bone, cutting of tendons, and insertion of implants or pins to straighten toes may be used to restore the normal shape of the foot.2

How RA affects the ankle

In RA, joints in the ankle may become inflamed and swollen. Difficulty walking up ramps or stairs may be early signs of RA involvement in the ankles. As the ankle joint becomes damaged by RA, standing and walking may become more painful.2

Surgery for the ankle

If joint symptoms do not respond to medication or other management approaches, surgical interventions may be used. Surgical options include arthrodesis (fusion of affected joints) and arthroplasty (total ankle replacement). Both of these approaches are effective in reducing pain and improving mobility and function. Fusion of joints involves removal of the joint and fusion of two bones into one. Ankle replacement is typically considered for patients who have already had a fusion of joints or where there is severe involvement of the joints in or near the ankle.2

Risks of surgery

All surgeries come with risks, such as infection, failure to heal, or loosening of the devices places into joints. Some people may need repeat surgeries on a particular area. Certain surgeries, like those involving the forefoot, put more stress on the blood vessels and skin of the foot. In rare cases, amputation of a portion or a whole toe may be necessary.2,4

Written by: Jonathan Simmons and Emily Downward | Last reviewed: May 2018.
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